Playing Nice in the Sandbox: How to Handle Patients Hooked on CAM

Did you enjoy watching the 2016 Summer Olympics as much as my family and I did? We were glued to the TV for nights on end, delighting in Simone Biles and Aly Raisman on the mat, Katie Ledecky in the pool, and Jeff Henderson on the track, long jumping towards gold. We marveled at the giftedness and determination of the athletes, the cohesiveness of the teams, and the stories of family support and sacrifice. But there was one thing that my kids found perplexing– They scratched their heads and asked me, “Mom, what are those?” And I have an honest question for you: how many of you rolled your eyes a bit when you saw THOSE?

 

Cupping is just one in a long list of techniques included in Complementary and Alternative Medicine (CAM). As PTs, we field questions daily about the benefits of various treatments: “Does that cupping really work? Should I try acupuncture? My sister is studying Reiki—should I have her work on me? My chiropractor said my rib keeps popping out, so I need to see him weekly. Should I still do the PT exercises when it’s out?” As evidence-based practitioners, it can be very easy to become cynical about the explanations and interventions our patients are receiving from CAM providers, but before we roll our eyes or blurt out our gut reactions, let’s pause to think of this from a pain perspective.

First, a few definitions and statistics:

Complementary Therapies: Therapeutic interventions utilized in addition to traditional medical care, to supplement the mainstream remedy. A good example is someone who goes to yoga in addition to taking an anxiety medication to help get a handle how they respond to stress in their lives.

Alternative Medicine: Therapeutic interventions utilized instead of, or as a substitute for, traditional care. An example is someone who talks to their life coach about their anxiety and applies their advice without seeking help from a psychiatrist, psychologist, or licensed professional counselor.

Integrated Medicine: A growing field, which incorporates a combination of traditional and alternative techniques. Physicians practicing as in integrated medicine may prescribe both FDA approved medications as well as supplements and “Eastern” or other modalities to help patients with complex issues.

Complementary and Alternative Medicine (CAM): A broad category encompassing both supplemental and alternative modalities. These can be further divided into 5 categories:

Mind-Body Therapies Treatments that focus on how our mental and emotion status interacts with our body’s ability to function Examples: Meditation, Art therapy, Music
Whole Medical Systems Complete systems of medical theory and practice, many of which go back thousands of years and have roots in non-Western cultures Examples: Chinese medicine, Aryuveda
Manipulative and Body-based Therapies A practice intended to improve specific symptoms and overall health by relying on the physical manipulation of the body Examples: Chiropractic, Osteopathy
Energy Medicine Uses energy fields to promote healing. Biofield therapies affect energy fields that are said to encircle the human body. Examples: Reiki, Qi Gong, Magnet Therapy,
Biologically Based Practices Focus on herbs, nutrition, and vitamins, dietary supplements and herbal medicine. Examples: Nutritional counseling from those other than registered dietitians

Gildhayal et al. recently published a study entitled “Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population”. The free article can be found here.  Of 34,525 respondents surveyed, 9,665 participants reported having LBP within the last 3 months. In all, 41.2% of the LBP population used CAM in the past year, with higher use reported among those with limiting LBP. The most popular therapies used in the LBP population included herbal supplements, chiropractic manipulation, and massage. The majority of the LBP population used CAM specifically to treat back pain, and 58.1% of those who used CAM for their back pain perceived a great deal of benefit.

A slightly older survey by the CDC showed that 36% of 31,000+ respondents had used CAM the previous year (62% if prayer was considered part of CAM). Of note, 13% of CAM users used it because they felt conventional medicine was too expensive, and 28% used it because they believed conventional medical treatments would not help them with their health problem.

People are looking for answers for their pain. It behooves us as PTs to ask, “Where are they looking?” In April 2005, an ABC News/USA Today/Stanford University Medical Center poll was conducted by telephone, among a random national sample of 1,204 adults. The results have a three-point error margin:

pain-remedies

Do you guys notice anyone who is missing from that chart? Where are WE??? Are we seriously sought out less that marijuana and booze? (Ummm…maybe don’t answer that). Were we even offered as a choice on the survey, and if not, why not? Have we not educated the general population that we are very good at treating pain? And, if asked, do you think 58% of patients with low back pain would answer that they received a “great deal of benefit” from physical therapy? Are we very good at it? How many patients have you seen who reported a low expectation for benefit, as they have tried PT in the past with little relief?

So, we are left in a conundrum. Many of our patients are seeking and regularly receiving CAM interventions. Many of them strongly believe it has been beneficial. They have great relationships with their providers and have no intention of giving that up. Yet when we hear the explanations that they have been told, our skin crawls. We also know that multiple explanations for why someone hurts are one of the “yellow flags” that tend to drive up the pain experience. Conflicting information can perpetuate tissue-based models and make it hard for us to “sell” neuroscience education. How do we contend with this?

One possible answer: Cut the ties. I have heard many PTs state that they tell patients they will not see them if they continue to receive services from their chiropractor/massage therapist/etc. This view has many advantages: we now have the patient all to ourselves and can assure that no misleading or scary information is being fed to the patient. We can help them understand the difference between pain issues and tissue issues and find a path to reasonable self-care. We can help break cycles of passive treatment and life-long dependence on others for relief. Of course this is the correct answer…right?

Unfortunately, there are some cons to taking a hard line on “cut the ties.” We all know how important therapeutic alliance is. Once a bond of trust has been forged between a practitioner and patient, anything that threatens that bond (i.e. you, the well-meaning PT, taking their chiropractor away from them…the chiropractor that has been the only one holding them together for the past seven years…), becomes a threat to the patient. And what happens when threat goes up? The alarm system activates and pain increases. Great—we’ve just shot ourselves in the foot, and we haven’t even gotten to know our patient yet. Another con is that sometimes we can be perceived as haughty or disrespectful towards another professional. Clearly, talking poorly about another practitioner does not reflect anything positive on us and undermines any therapeutic alliance that we are trying to build.

Another possible answer: Avoid the conversation. Just teach the patient “the truth” (at least our version of the truth…which just so happens to be STRONGLY rooted in evidence supporting the neuroscience of pain). Teach them pain science well enough and provide such excellent all-around care that they will come to their own conclusions about CAM and eventually stop seeing the others because we are Just. That. Good. But, as Patrick Wall said, “If we’re so good then why are our patients so bad?”

A third option: Go along with whatever narrative the patient believes. If they are convinced that rib keeps “popping out,” tell them you have a great exercise to help decrease the frequency of that. It makes sense to the patient, they are willing to try your advice, and they’ve already bought-in. Is that so wrong?

These are the questions I struggle with daily (and on occasion, keep me up at night!). To be honest, I have implemented all three of these options, and others, as the situation demands. I have made mistakes, sounded like a snob, alienated some folks, but also built bridges. I have worked hard to be honest with patients about what I think is going on with them, while trying to preserve a level of professional respect for the opinions of others. As a direct-pay practitioner, I see a large percentage of patients who are currently seeing CAM providers. They are happy to pay for highly skilled, individualized care, provided by a consistent therapist each visit…they have become accustom to that from the other clinicians in their world and now they are seeking the same in PT-Land. Heck, I see many CAM providers as patients! They have become some of my biggest referral sources, and generally, they buy in and are greatly appreciative when I share pain science with them.

I know we as PTs have essentially been trained from birth to hold certain other “professions” in a certain degree of suspicion, or dare I even say, contempt. But as we look at an epidemic facing our nation, where we lose more people to opioid overdoses every two months than we lost in 9/11, we have to ask: who is the real enemy here? Can we build bridges with our CAM providers for the greater good of our patients? Are they all full of cr–? Are they sly business people just out to make a buck off others’ pain and fear? Or are they (at least a good portion of them), well-intended, empathetic people who want to help others and are just seeing the patient through the filter of their own professional upbringing? We are all drinking Kool-Aid of one type or another, and for the sake of our patients, I hope we can figure out how to stay hydrated with our flavor of choice and still play nice in the sand box together.

Please share your thoughts…how do you walk the mainstream/CAM tight-rope? What common ground can we find, and what are some strategies to build bridges with those with whom we disagree?

6 responses to “Playing Nice in the Sandbox: How to Handle Patients Hooked on CAM

  1. Tim Mondale says:

    Jessie,

    Thanks for the post. It’s an interesting topic, and I have long wondered why we weren’t ever considered on that list of practitioners that could be considered CAM? Perhaps because we may exist in both the conventional medical approach side, as well as the CAM…never really been sure. I think it would benefit us in many ways to be thought of as on that list of options.

    To the larger question of how to handle our patients that partake of other strategies, as long as it doesn’t get in the way of what I am trying to get through to them from an understanding standpoint, I don’t usually advocate for any change in that way. However I do think it’s valid that if someone else might be doing similar things to similar systems that from a medico-legal standpoint (without disparaging), as well as a messaging standpoint that is probably not good for the patient. In addition it makes it near impossible to know what the effects of what we have done, versus what someone else has done.

    In the example you gave, answering a nonsensical “your rib keeps popping out” with another nonsensical “exercise that can keep it in”; I’m not comfortable with that. I think it only leads to bigger problems in the long run. I routinely ask patients to not see their chiropractors during the time that I will be seeing them. I know and agree it’s our Kool-aid, but done skillfully, I think the evidence of our Kool-Aid, and supportable understandable and manageable explanations are far superior to those made up out of convenience.

    Thanks for the post Jessie

  2. Jessie Podolak says:

    Thanks for your reply, Tim! You raise a good question: why isn’t PT considered CAM? Certain techniques employed by PTs certainly nudge the line (blurry as it is) between conventional medicine and alternative treatments. Many of our patients view us in the same light as their CAM providers, and reimbursement often covers more visits of chiropractic care than PT! Very interesting “categorizations” to be sure.

    Re: the example I posed, thanks for your input on that! I too feel your discomfort with the option of “let’s put it back in.” We cannot continue to reinforce false narratives. I admit that in my younger (less confident) days as a PT, I didn’t always confront those narratives, and sometimes I went along with “whatever worked” for the patient to keep them happy. (Not proud of it, but I did it!!)

    I think it’s actually an advanced “soft skill” to word explanations in a way that is truthful, re-directing, yet still respectful of other treatment philosophies. Does this sound better? “Well, this rib problem seems to be an ongoing issue. Perhaps a little different approach will help. I have a couple of exercises that I would like you to try for a while. I’ve seen people with similar symptoms respond really well when they do these consistently.”

    I too have asked patients to let me have a shot at their problem without others (most often chiropractors) treating them concurrently. Most of the time
    people get it and are happy to have a break from too many appointments. However, the point I wanted to raise is that SOMETIMES, asking a patient to pause their CAM can actually be a threat, so we have to be flexible and remember that it’s always about the patient.

    Appreciate your insight!
    Jessie

  3. Mike Terrell says:

    My practice is part of a multidisciplinary chronic pain rehab program (focus on function instead of pain relief). As you might imagine, most of our patients come having tried a variety of different treatments that fall under the CAM umbrella. Anything to get rid of this pain, right?
    This is how I generally approach that patient. First, I listen to them and try to gather a basic understanding of them as a person. Where are they coming from? What are they looking for? Second, I do a thorough examination to gather as much information about them as possible. Third, I provide rational, evidence-based explanations for their issues, this is important, when I sense they are ready to hear what I have to say.
    Throughout treatment, whether they know it or not, I am gently nudging them toward self-management and self-efficacy. I am trying to empower them to not only treat themselves but to truly understand themselves, from the biopsychosocial perspective.
    The better the rapport I have with the patient, the more blunt and directly honest I will be. If I am still building that rapport, I will try to come at the issue indirectly to avoid the threat and resistance Jessie referenced.
    Do I do it perfectly? Nope. I have hosed it up in the past and I will in the future, but this approach generally works well.

    1. Jessie Podolak says:

      Mike,

      There is so much wisdom in your post. Thank you! I think we actually earn the right to share our explanations as we build trust with our patients. It sounds like you have a great ability to forge a therapeutic alliance, embrace and communicate pain neuroscience education, and empower your patients for self-care. I really appreciate your humility too, and I bet the “hosings” (love that) are coming fewer and farther between as you navigate the muddy waters of treating pain from a biopsychosocial framework! Great stuff!

      Jessie

  4. Yvonne Mlynarcyk says:

    I did a research paper in the early 90s that showed this exact trend. Even back then the medical community knew that people were consistently seeking and paying out-of-pocket for “alternative medicine”. Back then I came across the quote, “All medicine was, at one time, alternative.” Through the years, the terminology changed from alternative medicine to complementary medicine. (If you can’t beat them – join them.)

    As physical therapists who are seeking to validate our interventions, I believe we must remain cognizant of one essential question – Does our research guide our practice, or does our practice guide our research?

    1. Jessie Podolak says:

      Yvonne,

      Thanks for your insights! What a great quote: “All medicine, at one time, was alternative.”

      It would be really interesting to look at some qualitative research comparing “conventional practitioners” attitudes regarding CAM in the nineties to present day, wouldn’t it?

      Thank you!
      Jessie

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